Gaining perspective on messenger RNA coronavirus disease 2019 vaccination risk
Authors: Warren R. Heymann
Journal: Journal of the American Academy of Dermatology (2023)

Discussing COVID-19 vaccinations will be ongoing ad infinitum. "Vaccine makers should target the XBB variant of the coronavirus in a shot to be available in the fall," according to an advisory panel to the Food and Drug Administration. Although the COVID-19 landscape has improved this year, "those who remain vulnerable include the unvaccinated; people who are immunocompromised; and those who have diabetes or chronic kidney, lung, cardiovascular or neurologic diseases. People 65 and older are also at risk and that rises with age."1Jewett C. F.D.A panel advised vaccine makers to aim at only one covid variant. New York Times.https://www.nytimes.com/2023/06/15/health/fda-covid-vaccine-boosters-xbb.htmlDate accessed: June 17, 2023Google Scholar Despite our advances, questions regarding vaccination remain abound, especially for the mRNA-based vaccines (BNT162b2, Pfizer-BioNTech and mRNA-1273, Moderna). Most clinicians have likely encountered patient(s) developing a dermatosis within a few weeks of receiving these vaccines and are curious if the vaccine was the inciting culprit. In the October 2023 issue of the Journal of the American Academy of Dermatology, Ju et al2Ju H.J. Lee J.Y. Han J.H. Lee J.H. Bae J.M. Lee S. Risk of autoimmune skin and connective tissue disorders after mRNA-based COVID-19 vaccination.J Am Acad Dermatol. 2023; 89: 685-693https://doi.org/10.1016/j.jaad.2023.05.017Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar assessed the risk of developing autoimmune and connective tissue disorders after mRNA-based COVID-19 vaccinations. A total of 3,838,120 vaccinated individuals and 3,834,804 historical controls without evidence of COVID-19 were included. The risk of alopecia areata, psoriasis, vitiligo, antineutrophil cytoplasmic antibody–associated vasculitis, sarcoidosis, Behçet disease, inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, Sjögren syndrome, ankylosing spondylitis, dermato/polymyositis, and bullous pemphigoid was not significantly higher in vaccinated individuals than in controls; however, there was an increasing trend for the risk of antineutrophil cytoplasmic antibody–associated vasculitis and bullous pemphigoid. The risk of myocarditis, pericarditis, and thrombocytopenia was increased in vaccinated patients compared to controls. The authors concluded that most autoimmune connective tissue disorders are not associated with a significant increase in risk from vaccination, although they advise caution when interpreting results for rare outcomes due to limited statistical power.2Ju H.J. Lee J.Y. Han J.H. Lee J.H. Bae J.M. Lee S. Risk of autoimmune skin and connective tissue disorders after mRNA-based COVID-19 vaccination.J Am Acad Dermatol. 2023; 89: 685-693https://doi.org/10.1016/j.jaad.2023.05.017Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Anyone who develops a disease following a COVID-19 vaccination will easily find literature to support their suspicion that the vaccine was causative. Most are case reports or small case series. Examples include a 63-year-old Saudi hypertensive, diabetic woman whose generalized morphea started appearing 2 weeks after receiving her second dose of Pfizer-BioNTech COVID-19 vaccine3Alhayaza R. Alhayaza G. Algarni A. Alhumidi A. AlHarithy R. Generalized morphea following COVID-19 vaccine: Case report and literature review.Clin Case Rep. 2023; 11: e7133https://doi.org/10.1002/ccr3.7133Crossref PubMed Google Scholar and a 67-year-old Japanese woman who developed cutaneous IgA vasculitis and nephropathy the day she received the second dose of the Pfizer-BioNTech COVID-19 vaccine.4Sugita K. Kaneko S. Hisada R. et al.Development of IgA vasculitis with severe glomerulonephritis after COVID-19 vaccination: a case report and literature review.CEN Case Rep. 2022; 11: 436-441https://doi.org/10.1007/s13730-022-00695-1Crossref PubMed Scopus (20) Google Scholar The mechanism(s) causing these reactions remains undetermined—perhaps, molecular mimicry between SARS-CoV-2 and vaccine components is at play in some cases. As all of these disorders existed in the pre–COVID-19 era, coincidence is always a consideration (your unfortunate patient with autoimmune or connective tissue disorders postvaccine will not believe it). It is our responsibility to put this in perspective for patients concerned about the risk of developing autoimmune or connective tissue diseases from the vaccine, or whether or not to take the vaccine if they have these diseases. I concur with Kasperkiewicz and Woodley5Kasperkiewicz M. Woodley D.T. COVID-19 and autoimmune bullous diseases: lessons learned.Autoimmun Rev. 2023; 22103286https://doi.org/10.1016/j.autrev.2023.103286Crossref PubMed Scopus (4) Google Scholar who state, "the association between COVID-19 vaccination and AIBDs [autoimmune bullous disorders] remains uncommon or even coincidental. This should encourage COVID-19 vaccination in patients with AIBDs, particularly in those whose disease is controlled at the time of vaccine administration, since benefits of vaccination far outweigh this questionable risk." None disclosed. CorrectionJournal of the American Academy of DermatologyVol. 90Issue 1PreviewThe article by Ju et al (Risk of Autoimmune Skin and Connective Tissue Disorders After mRNA-based COVID-19 Vaccination. J Am Acad Dermatol. 2023; 89(4):685-693) was erroneously excluded from the September 2023 issue. It is published in the October 2023 issue. The "This Month in JAAD" and "A Clinician's Perspective" articles in the September 2023 issue have been updated online to direct readers to the article in the October 2023 issue. Full-Text PDF